A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.

A. Increase hematocrit: Fluid overload typically leads to hemodilution, resulting in a decrease in hematocrit rather than an increase. Therefore, an increase in hematocrit would not be expected in a client with fluid overload.
B. Increased temperature: Fluid overload is not typically associated with an increased body temperature. Instead, fever may indicate an infection or another underlying cause. Therefore, an increased temperature would not be a typical finding in a client with fluid overload.
C. Increased heart rate: Fluid overload can lead to an increased heart rate as the body attempts to maintain adequate cardiac output in the presence of excess fluid volume. An elevated heart rate is a compensatory mechanism to maintain tissue perfusion despite the increased workload on the heart.
D. Increased respiratory rate: Fluid overload can cause pulmonary congestion, leading to increased respiratory effort and a higher respiratory rate as the body attempts to compensate for decreased gas exchange efficiency. An increased respiratory rate helps to improve oxygenation and remove excess carbon dioxide from the body.
E. Increased blood pressure: Fluid overload often leads to increased blood pressure due to the increased volume of circulating blood, which can strain the cardiovascular system. Elevated blood pressure is a common manifestation of fluid overload and reflects the increased workload on the heart and blood vessels.